Preparation Instructions for Lower EUS - Nulytely/Golytely

Transcription

1 Physician: Patient Name: Date of Procedure: Location: Phone Number: Time to Arrive: Preparation Instructions for Lower EUS - Nulytely/Golytely Welcome to the MGH GI Endoscopy Unit. We would like to make your stay as pleasant and safe as possible. Please read these instructions carefully before your Lower EUS. Please plan to spend about 3 hours in our unit for your procedure. We will do everything possible to avoid a delay in your procedure, but emergencies may interrupt the schedule. Please check the location of your procedure; we now have 3 sites (MGH-Blake 4, Charles River Plaza-165 Cambridge Street, 9 th floor, and Danvers). BEFORE you start to prepare for your procedure: Call your insurance company for an insurance referral, if required. Update your MGH registration information at , if you have not done so within 6 months. If you receive sedation, you MUST have an adult escort to take you home after the procedure. Your escort does not have to come with you when you check in but must meet you in the endoscopy unit when you are ready to go home. You are still required to have an adult escort even if you plan to take the T or a taxi home. You are not allowed to drive until the next day. If you don t have an escort on the day of your procedure, your procedure will be CANCELLED and rescheduled. If your procedure is scheduled at Charles River Plaza, and you use a CPAP for sleep apnea or oxygen at home or have an implanted defibrillator, please call the doctor s office at the phone number above immediately to reschedule your procedure for Blake 4. FIVE DAYS before your procedure: 1. Purchase Nulytely or Golytely with the enclosed prescription. If you have constipation or use a laxative even occasionally, purchase Milk of Magnesia. 2. Purchase a simethicone anti-gas product (Gas-X, Mylanta Gas, Maalox Anti-Gas, etc.). 3. If you have diabetes and take medication to control your blood sugar, contact your primary care physician or diabetes doctor for instructions about how to take your diabetes medication while preparing for this procedure. 4. Please do not eat any raw fruits or vegetables for the next 5 days. Cooked fruits and vegetables and nuts are permitted. TWO DAYS before your procedure: 1. Be sure you have the Nulytely or Golytely from your pharmacy. 2. If you have constipation or use laxatives more than twice a month, take 4 tablespoons of Milk of Magnesia at bedtime. ONE DAY before your procedure: 1. Begin a clear liquid diet starting at breakfast. You may not have any solids today. A clear liquid diet includes any liquids you can see through, such as water, tea, black coffee, clear broth, apple juice, Gatorade, white grape juice, soda, Jell-O. Do not eat or drink anything red. Do not drink milk or other dairy products. It is important that you drink at least 8 glasses of liquid through the day in addition to the prep to avoid dehydration. 2. Mix the laxative preparation as directed in the package and refrigerate for 2 hours. You may add a flavor pack if enclosed or lemon flavored Crystal Lite. 3. Follow the instructions below for taking the laxative, not the instructions included in the preparation package. Last Updated: 11/14 Form: PP-EUS-01

2 Beginning at 6 pm, drink 8 ounces of the prep solution every minutes until approximately ½ of the prep solution is consumed. Keep drinking the solution on schedule even though the laxative action may not begin for 2-3 hours. If you become nauseated, wait 30 minutes, then resume drinking but taking in smaller amounts. Drinking the solution through a straw can make it more palatable. Chewing gum or sucking on a hard candy or lollipop between doses can help with tolerability. Use baby wipes if your anal area becomes irritated from frequent bowel movements. Place the container in the refrigerator overnight. 4. At 9 pm, take 2 gas tablets with 8 ounces of clear liquid. 5. At 10 pm, take 2 gas tablets with 8 ounce of clear liquid. 6. Please complete the enclosed Patient Medication List and History Form and bring them with you. Read the enclosed sample consent form. You do not need to bring the consent form with you. You will be asked to sign a copy in the procedure area before your procedure. ON THE DAY of your procedure: 1. 4 hours before your scheduled arrival time, drink the remaining prep solution. Drink 8 ounces every minutes until the solution is finished. Note that this may require you to awaken very early in the morning in order to complete the prep. Although inconvenient, the correct timing of drinking the prep is crucial to obtaining a good colon preparation. 2. Take all of your usual medicines including medicines for high blood pressure with a small amount of water. If you take Coumadin and/or Plavix, do not stop these unless you are told to. If you take insulin, we recommend that you take ½ your usual dose. We will check your blood sugar prior to the procedure. 3. If you have a medical condition requiring antibiotics before or after procedures, we will determine whether they are needed for your Lower EUS. 4. STOP CLEAR LIQUIDS 2 HOURS BEFORE YOUR PROCEDURE (except for small amounts of water with medications). 5. Do not chew gum on the day of the procedure. 6. Do not wear jewelry to your procedure other than wedding rings or bring valuables such as electronics. We cannot be responsible for lost valuables. Please bring these things with you to your procedure: 1. Your completed Patient Medication List and History Form. 2. The name and phone number of your escort. 3. Photo identification 4. Do not wear jewelry other than wedding rings. AFTER your procedure: 1. You will be monitored in the Endoscopy Unit recovery area for approximately one hour. 2. You will receive diet and medication instructions after your procedure. 3. You may return to work the day after the procedure. If you have questions about your procedure, call the Patient Information Line at (617) and leave a message. Messages are checked several times a day. A registered nurse will return your call during regular business hours Monday through Friday. If you need to speak with someone at other times please contact your doctor s office. The phone number is listed on the top of the first page of the preparation instruction sheet. Last Updated: 11/14 Form: PP-EUS-01

3 PATIENT IDENTIFICATION AREA PATIENT CONSENT TO PROCEDURE PATIENT: UNIT NO: PROCEDURE: LOWER GI ENDOSCOPIC ULTRASOUND (LOWER EUS) Right Left Both Sides Not applicable My doctor has told me and I understand what procedure/surgery I am having done. I understand why I need it, the possible risks (like drug reactions, bleeding, infection, and complications from receiving blood or blood components), and that there is no guarantee of results. My doctor has also explained what might happen to me if I don t have this procedure, other choices I can make instead of having this done, (including choosing no treatment) and what can happen to me if I choose to do something else. I understand that with any procedure, problems could come up that we did not expect. My provider explained to me how he/she prevents infections related to my health. The following additional risks or issues were explained to me: An examination of the lower colon with ultrasound is performed with an endoscope that uses an ultrasound transducer or camera. The procedure requires careful preparation in order to clean the colon. The purpose of the procedure is to examine a lesion in the colon. Ultrasound images will be obtained in order to identify the lesion and guide a biopsy in some instances. Anesthesia care might be used to provide sedation during the procedure. Lower EUS is considered a rather safe procedure. However, you might feel cold water being instilled into your rectum and cramps from the passage of the scope. The procedure, biopsies, and/or polyp removal could result in bleeding or a perforation to the colon. A perforation (hole in the colon) would require emergency surgery in order to repair the colon. If procedural sedation will be used during this procedure to control my pain, I understand that this method of pain control has risks. These risks include difficulty breathing that may require breathing support and decreased blood pressure. The most common side effects are nausea and vomiting. In rare cases, there can be allergic reactions or cardiac arrest (stopping of the heart). Lastly, I may have pain, even after using these medications. Doctor will perform my procedure/surgery. I understand that Massachusetts General Hospital (MGH) is a teaching hospital. This means that doctors and students in medical, nursing, and related health care professions receive training here and may take part in my procedure/surgery. My doctor will be there for the important parts of my procedure/surgery. My doctor will determine when other providers need to participate in my procedure/surgery and care. I understand that this procedure/surgery may have educational or scientific value. The hospital may photograph, videotape, or record my procedure/surgery for educational, research, quality and other healthcare operations purposes. Any information used for these purposes will not identify me. I understand that blood or other samples removed during this procedure may later be thrown away by MGH. These materials also may be used by MGH, its partners, or affiliates for research, education and other activities that support MGH s mission. I have had the chance to ask questions about the risks, benefits and alternatives to this procedure/surgery. I am happy with the answers I received. I consent to this procedure/surgery. Date Time AM/PM Signature (patient/health care agent/guardian/family member) (If patient s consent cannot be obtained, indicate reason above.) I attest that I discussed all relevant aspects of this procedure/surgery, including the indications, risks, and benefits, as compared with alternative approaches, with the patient, and answered his/her questions. Date Time AM/PM (5/13) Signature (Physician/Licensed Practitioner) 3 of 5

4 GI Endoscopy Patient History Form Page One Patient Identifier Area Language and Communication Primary Language: English What language do you prefer your healthcare to be discussed in? English Do you need assistance with your paperwork? Yes No If yes, please notify secretary for assistance Do you have problems with your vision? Yes No Glaucoma Legally blind Glasses/Contact Lenses Do you have problems with your hearing? Yes No Hearing Aids: Right Left Allergies Do you have any medication allergies? Yes No If yes list: Do you have a latex sensitivity/allergy? Yes No If yes describe reaction: Do you have any food allergies? Yes No If yes list: Basic Medical History: Height: ft. in. Weight: lbs or kgs Have you had any recent weight changes? Yes No If yes: Gain Loss Do you have any dietary restrictions? Yes No If yes: Diabetic Gluten free Smoking status? Yes No If yes: packs/day: Do you drink alcohol? Yes No If yes how much? History of alcohol dependency? Yes No History of recreational drug use? Yes No Are you pregnant? Yes No Possibly N/A Do you have obstructive sleep apnea? (OSA) Yes No Do you use: CPAP or BIPAP What are your settings? Do you use your machine when on vacation? Yes No Indication for Procedure: Why are you having this procedure today? Routine Screening Crohn s/ulcerative Colitis Gallbladder Stones Stent Removal /Placement Pain Diarrhea Reflux (GERD) Stricture Anemia History of Polyps Trouble Swallowing History of Ulcers Bleeding Barrett s Esophagus Pancreatic Cyst I m not sure Constipation Esosinophilic Esophagitis Pancreatic Mass Family History Reviewed By: RN Date Time Triaged By: RN Date Time

5 GI Endoscopy Patient History Form page two Patient Identifier Area Surgical History: Please list surgical procedures: Abdominal, Pelvic, Yes No Appendectomy Cholecystectomy (gallbladder) Weight Loss GI Surgery Hysterectomy Colectomy (bowel resection) Fundoplication Heart/Lung Yes No Bypass Valve Stent Placement Angioplasty Lung Resection Lobectomy Transplant Yes No If yes: Organ Other Surgery: Yes No Tonsillectomy/Adenoidectomy Medical History: DO YOU HAVE you or HAVE YOU EVER HAD any of the following conditions? Gastrointestinal Cardiac Lung Neurological Mental Health Kidney Vascular Orthopedic Blood Disorders/ Immune Endocrine Familial Polyposis Pancreatitis Hepatitis Cirrhosis Pancreatic Cyst Varices Ulcers High Blood Pressure Atrial Fibrillation Heart Attack Coronary Artery Disease Congestive Heart Failure Cardiomyopathy Aortic Stenosis Pacemaker Murmur Defibrillator Other: Asthma Emphysema COPD Pulmonary Hypertension Pulmonary Embolism Home Oxygen Obstructive sleep apnea Do you use a BiPAP/CPAP Machine? What are your settings? Stroke Seizure ADD/ADHD Carotid Stenosis Alzheimer s Autistic Spectrum Multiple Sclerosis Parkinson s Developmental Delay Anxiety Depression Schizophrenia Bipolar Panic attack Other : Kidney Failure Last dialysis date: Aortic Aneurysm Peripheral Vascular Disease Blood Clots Joint replacement: Hip Knee Right Left Metal screws or plate Von Willebrand Hemophilia HIV Immunosuppressed Diabetes Cancer Colon Pancreatic Esophagus Liver Is there anything else you would like us to know? Form completed by: Patient Signature: Date Time Other Signature: Date Time Reviewed By: RN Triaged By: RN Date Time Date Time

6 Parking Information & Directions Blake Building, 4 th Floor 55 Fruit Street, Boston, MA Parking: Fruit Street Garage or Parkman Street Garage Garages are located off of Cambridge Street Directions from the garage: After parking in the Fruit Street -or- Parkman Street Garage Enter through the Main entrance Take the E elevator to the 4 th floor of the Blake Building Once you exit the elevator, look for the glass door labeled GI Associates Charles River Plaza, 9 th Floor 165 Cambridge Street, Boston, MA Parking: Our Charles River location has two options for parking: 1. Charles River Plaza Parking Garage, 207 Cambridge Street this is the preferred parking location 2. Fruit Street Garage -or- Parkman Street Garage Directions from the garage: From the Charles River Plaza Parking Garage (Preferred Parking Location) Look for the Orange wall labeled 165 Cambridge Street Take the elevator to the 9 th floor The entrance will be on your left From the Fruit Street / Parkman Street Garages Walk down North Grove Street, take a left onto Cambridge Street After walking 2 ½ blocks, you will see the sign for Charles River Plaza on your left The 165 Cambridge St. building will be on the right of the plaza - enter through the glass doors Elevators are at the end of the hallway, go to the 9 th floor - the entrance will be on your left Mass General / North Shore, Endicott Street, Danvers, MA Parking: Center for Outpatient Care parking lot Directions from the garage: Enter through the Main Entrance Elevators will be straight ahead For Procedures: Take the elevators to the 2 nd floor For Office Visits: Take the elevators to the 3 rd floor Please visit the MGH Parking Office website for more information and directions to our locations: Last Updated: 8/14 Form: DD-01